Short Communication

Tim Joda The virtual patient in dental medicine

German O. Gallucci

Authors’ affiliations: Key words: cone-beam computed tomography, digital dental medicine, extraoral face scan,
Tim Joda, Division of Fixed Prosthodontics, School intraoral scan, superimposition, virtual patient
of Dental Medicine, University of Bern, Bern,
Switzerland
German O. Gallucci, Department of Restorative Abstract
Dentistry & BioMaterial Science, Harvard School of
Dental Medicine, Boston, MA, USA
Objectives: The aim of this Short Communication was to present a workflow for the
superimposition of intraoral scan (IOS), cone-beam computed tomography (CBCT), and extraoral
Corresponding author: face scan (EOS) creating a 3D virtual dental patient.
Dr. Tim Joda, DMD, MSc
Division of Fixed Prosthodontics Material and Methods: As a proof-of-principle, full arch IOS, preoperative CBCT, and mimic EOS
School of Dental Medicine were taken and superimposed to a unique 3D data pool. The connecting link between the
University of Bern different files was to detect existing teeth as constant landmarks in all three data sets.
Freiburgstr. 7
3010 Bern, Switzerland Results: This novel application technique successfully demonstrated the feasibility of building a
Tel.: +41 31 632 0910 craniofacial virtual model by image fusion of IOS, CBCT, and EOS under 3D static conditions.
Fax: +41 31 632 49 31 Conclusions: The presented application is the first approach that realized the fusion of intraoral
e-mail: tim.joda@zmk.unibe.ch
and facial surfaces combined with skeletal anatomy imaging. This novel 3D superimposition
technique allowed the simulation of treatment planning, the exploration of the patients0
expectations, and the implementation as an effective communication tool. The next step will be
the development of a real-time 4D virtual patient in motion.

Digital technologies have recently received
its way into dental medicine. Due to these
developments, clinical practices and labora-
tory techniques are shifting to virtual-based
processes (Eaton et al. 2008; Schoenbaum
2012). Routinely diagnostic methods include
digital radiology and photography; treatment
concepts benefit from modernized workflows
with intraoral scanning, computer-assisted
implant surgery, and streamlined manufac-
turing of dental prostheses (Patel 2010).
The fusion of these digital puzzle pieces to
a whole seems to be the logical continuum
of this trend: creating a 3D virtual patient.
The entire treatment plan could be simulated
noninvasively, shared via network-mediated
communication tools, and adopted to the
patient0 s expectation (Kau 2011; Katase et al.
2013). However, how far are we in virtual
dentistry? Today, there are (still) more ques-
tion marks than answers.
Therefore, the aim of this Short Communi-
cation was to update the current status of
knowledge as well as the technical progress
in the field of 3D virtual patients science,
and presenting a workflow for the superimpo-
sition of 3D imaging as intraoral scan (IOS),
cone-beam computed tomography (CBCT),
and facial extraoral scan (EOS).
Material and methods
A clinical case, requiring an implant-sup-
ported reconstruction for the replacement of
teeth 21 and 22, was chosen to demonstrate
the stepwise procedure creating a 3D virtual
patient prior to surgery:

Date:
Accepted 27 February 2014

To cite this article:

Joda T, Gallucci GO. The virtual patient in dental medicine.
Clin. Oral Impl. Res. 26, 2015, 725–726 Fig. 1. Pre- and post-extraction intraoral surface scans (IOS) as STL, cone-beam computed tomography (CBCT) as
doi: 10.1111/clr.12379 DICOM, and stereo-photogrammetric extraoral scan (EOS) as OBJ.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 725
Joda & Gallucci  The virtual patient
Fig. 2. Pre- and post-extraction frontal as well as lateral 3D virtual patient data sets based on superimposition of
IOS + CBCT + EOS.
Fig. 3. Prosthetic-driven treatment planning based on CBCT and IOS with 3D implant software.
First, full arch IOS impressions were taken
(iTero Align Technology, San Jose, CA, USA)
and stored as STL files. The STL format
describes triangulated surface geometries of
3D objects. Moreover, a CBCT was performed
(i-CAT, Hatfield, PA, USA). The correspond-
ing data format DICOM is a standard for han-
dling, storing, printing, and transmitting
information in medicine (ISO 12052:2006).
Finally, stereo-photogrammetric EOS comple-
mented the series of imaging techniques
(3dMD, Atlanta, GA, USA). Three EOS were
captured during different smile positions as
OBJ files. OBJ is a universally accepted geome-
try definition file format that represents 3D
color and texture information (Fig. 1).
Afterward, all media files were superim-
posed to a unique 3D data pool. This required
reproducibly detectable landmarks in every
part of the imaging files. Here, the connect-
ing link between STL, DICOM, and OBJ was
References
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remaining teeth as constant objects in all
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Results
As a proof-of-principle, this application tech-
nique successfully demonstrated the feasibility
of building a craniofacial virtual reality model
by image fusion of IOS, CBCT, and EOS. The
superimposition facilitated creating a 3D vir-
tual patient data set under static conditions.
Despite of these preliminary results, real-time
actions of the jaws, lips, and mimic muscles
could not be captured in a 4D prototype.
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on the untextured skin image of the cbct scan.
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© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Discussion
Currently, no application system in the dental
literature is known achieving a superimposi-
tion of STL, DICOM, and OBJ files to a 3D vir-
tual patient. The presented application
technique is the first approach that realizes
the fusion of intra- and extraoral surfaces com-
bined with skeletal anatomy imaging. Mean-
while, it has been only reported on two files-
related fusions of either IOS + EOS (Rangel
et al. 2008; Rosati et al. 2010) or CBCT + EOS
(Naudi et al. 2013; Xin et al. 2013).
The presented 3D superimposition of IOS,
CBCT, and EOS allows outstanding advanta-
ges in future dental medicine: (1) simulation
of treatment planning and discovering
patients0 expectation; (2) facility for more
effective patient and colleague communica-
tions as well as implementation in dental
education; (3) noninvasive imaging technique
for high-precision anatomical documentation;
and (4) wide-range use in the fields of maxil-
lofacial as well as plastic surgery.
The next step has to be the development of
a real-time 4D virtual patient in motion.
Even though, it is still feasible to extract a
single frame of 3D data from a captured 4D
video sequence and export this to an OBJ file
that could then be superimposed with CBCT
data. However, no commercially available
system is (yet) able to fuse a 4D sequence of
mimic facial movements onto DICOM, STL,
and OBJ files.
Acknowledgements: The authors
thank Dr. Oon Tian Tan and Dr. Alice
Frigerio (MEEI, Boston, MA, USA) for
collaboration, as well as Jesse Knowles
(3dMD, Atlanta, GA, USA) for technical
support.
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& Ferrario, V.F. (2010) Digital dental cast place-
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a technical evaluation. American Journal of
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